Provider Demographics
NPI:1487945820
Name:GANGAT, MOHEMMED YUSUF
Entity type:Individual
Prefix:MR
First Name:MOHEMMED
Middle Name:YUSUF
Last Name:GANGAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 LARCHMONT LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6384
Mailing Address - Country:US
Mailing Address - Phone:423-926-4436
Mailing Address - Fax:
Practice Address - Street 1:417 BOONES CREEK RD
Practice Address - Street 2:
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-5165
Practice Address - Country:US
Practice Address - Phone:423-753-9701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000012396183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist